Heterogeneous Echotexture Research Articles

Sternocleidomastoid tumor of infancy-Importance of cytopathological diagnosis and challenges.

Sternocleidomastoid tumor of infancy (SCMI) is a rare, benign self-limiting condition which occurs in the perinatal period. The goal of our study is to highlight clinicoradiological and cytopathological findings in these cases. A study was done at a tertiary level hospital, from January 2016 to December 2019. Thirteen cases were studied, out of which 11 were clinically suspected cases of SCMI tumor and two cases were clinically suspected as cervical lymph node tuberculosis which were finally diagnosed as SCMI on fine needle aspiration cytology (FNAC) evaluation. Drs. N. K., S. Z., S. S. K., and S. R. independently reviewed the original diagnosis. Clinical, ultrasonographical, and cytopathological features are highlighted along with follow-up of the cases. There were a total of 13 cases, out of which 11 cases were neonates and two cases were more than 1 month of age (2 months and 2.5 months). Male: female ratio was 10:3 and swelling was present more commonly on the right side of the neck. Ultrasonography predominantly showed non-cystic, bulky, and heterogenous echotexture of the sternocleidomastoid muscle. Smears were moderately cellular showing mainly singly scattered oval to spindle shaped fibroblasts along with degenerating and regenerating muscle fibers. FNAC along with adequate clinic-radiological correlation aids in early and reliable diagnosis and can help curtail complications.

Could computed tomography be used as a surrogate of endoscopic ultrasonography in the screening and surveillance of small gastric Gastrointestinal stromal tumors?

PurposeTo investigate whether computed tomography (CT) could be used for screening and surveillance of small gastric gastrointestinal stromal tumors (gGISTs). MethodA total of 162 pathologically confirmed small gGISTs (≤2 cm) between September 2007 and November 2019 were retrospectively enrolled. Thirty-six lesions received contrast-enhanced CT after they were identified by endoscopy and EUS, and forty-three lesions received CT alone before surgery. The detection rate of CT for ≤1 cm gGISTs (micro-gGISTs) and 1–2 cm gGISTs (mini-gGISTs) was investigated, and the detection rate of CT alone was compared with that of CT following endoscopy and EUS. The relationship between EUS- and CT-detected high-risk features were assessed. ResultsCT demonstrated a favorable detection rate for mini-gGISTs previously identified by EUS and endoscopy, whereas CT alone showed an inferior detection rate (100 % vs. 75 %, p = 0.02). CT showed a poor detection rate for micro-gGISTs, both for lesions received CT after identified by EUS and endoscopy, and those received CT alone (33.3 % vs. 14.8 %, p = 0.372). CT-detected heterogeneous enhancement pattern and presence of calcification were strongly correlated with heterogeneous echotexture (Spearman’s ρ=0.66, p < 0.001) and echogenic foci (Spearman’s ρ=0.79, p < 0.001) on EUS, respectively. CT-detected necrosis was moderately correlated with cystic spaces on EUS (Spearman’s ρ=0.42, p = 0.02). No correlation was found between EUS- and CT- assessed irregular border. ConclusionsCT could potentially be considered as a surrogate of EUS for surveillance of mini-gGISTs instead of micro-gGISTs, whereas couldn’t be used as a screening modality for either micro- or mini-gGISTs.

Hallazgos ecográficos de cambios hepatobiliares en un felino con Platynosomum spp.

Platinosomose is a parasite caused by the trematode Platynosomum spp., which accommodates the felines’ hepatobiliary system. As its clinical manifestations are nonspecific, complementary exams are indispensable for an effective diagnosis. This report aims to demonstrate the importance of diagnostic imaging, especially ultrasound as an important tool in detecting changes triggered by this parasite. A feline, male, mongrel, five years of age, weighing 2.55 kg, neutered, vaccinated only against rabies, delayed deworming, history of emesis, difficulty in defecating, colored and odorous urine. The liver parenchyma was distorted, showing heterogeneous echotexture. The gallbladder was enlarged with difficulty in delimitation, noting biliary duct dilations, with echogenic content, distant and irregular, with a characteristic of bile hypoperfusion, using intra and extrahepatic obstruction. Clinical therapy was instituted and a return was requested for a reassessment of animals that underwent necropsy with cholangitis, biliary tract evidently with ectasia being detected, and examples of Platynossomum spp.

Overlap between systemic sclerosis and polyarteritis nodosa: A case report

BackgroundSystemic sclerosis (SSc) is a multiorgan connective tissue disease characterized by vasculopathy, inflammation, autoimmunity, and fibrosis in the skin, lungs and other organs. The occurrence of frank vasculitis is uncommon. Case presentationA 36-year old male patient with limited cutaneous SSc developed multiple necrotic ulcers on both legs and feet and gangrene of several toes, followed by an acute onset of axonal sensorimotor neuropathy affecting both radial and peroneal nerves, severe testicular pain with gangrenous patches over the scrotum. The hepatitis B virus (HBV) core antibody was positive while HB surface antigen and surface antibody, HAV and HCV antibodies were negative. The polymerase chain reaction for HBV and HCV showed no detectable viraemia. Antineutrophil cytoplasmic antibodies, cryoblobulins, anticardiolipin antibodies, lupus anticoagulant, antimitochondrial and anti- liver-kidney microsomal antibodies were negative. Pelvi-abdominal ultrasound and portal vein Doppler study showed a coarse and heterogeneous echo-texture of the liver, splenomegaly, moderate ascites and an enlarged, patent portal vein. Fibroscan revealed grade III liver fibrosis. He had an attack of haematemesis with elevation of the liver enzymes and low serum albumin and prothrombin concentrations. He was diagnosed as a case of polyarteritis nodosa. He was successfully treated by methylprednisolone intravenous pulses, followed by oral prednisone 40 mg/day. Plasmapheresis and six monthly doses of 1000 mg intravenous cyclophosphamide. Prednisone was gradually tapered to 5 mg/day with addition of azathioprine 100 mg/day. ConclusionThe association between systemic sclerosis and polyarteritis nodosa is very rare. The co-existence of SSc and vasculitis necessitates modification of the treatment plan.

Sa1473 CONTRAST-ENHANCEMENT ENDOSCOPIC ULTRASOUND FOR PANCREATIC NEUROENDOCRINE TUMORS: EXPERIENCE FROM ONE SINGLE INSTITOTION OF TAIWAN

Neuroendocrine tumors of the pancreas (pNET) are less common than pancreatic ductal adenocarcinoma. Endoscopic ultrasound (EUS) is recommended as the method of choice for detection of very small pancreatic tumors. Contrast-enhanced endoscopic ultrasound (CE-EUS) is helpful in characterizing pancreatic tumors which are incidentally found on other imaging. However, little known about how pNET in different grades present on CE-EUS. In our study, we used an ultrasound contrast agent (Sonazoid®) with microbubbles and investigated the characteristics of diagnosed pNET (particularly at an early stage) through CE-EUS by imaging the uptake of the microbubbles by the macrophages. The objective of this study was to examine the characteristics of pNET in different grades on CE-EUS. We retrospectively analyzed the characteristics of CE-EUS of pNETs confirmed by EUS-FNA or surgical pathology at our hospital between Dec. of 2018 to July of 2019. Using an EUS device compatible with operations in the contrast harmonic mode, after B-mode observations, we intravenously administered 7.5 μl/kg of Sonazoid® and conducted longitudinal observations from an early stage, which included up to 180 seconds in the contrast mode. We investigated the changes in the pancreatic tumorous findings before the contrast enhancement and in the early and later phases. Among 5 patients with histologically proved pNETs during the study period, one patient had 3-cm pancreatic mass with pathological diagnosis with combination of adenocarcinoma and NET which CE-EUS demonstrated persistent hypo-enhancement with heterogeneous echogenicity of the parenchyma which was similar finding as the adenocarcinoma of pancreatic cancer. One patient had diagnosed as 2.5-cm grade 2 pNET with hyper- and hypo-enhanced lesion and somewhat heterogeneous echotexture under CE-EUS. Another 3 patients with size from 0.5 to 4cm with diagnosed as grade 1 low grade pNET had the imageing of CE-EUS mostly with hyper-enhancement at early stage and hypo-enhancement at delayed phase with homogeneous echogenicity. The CE-EUS findings between different differentaion of pNET became distinct, thus suggesting that CE-EUS may be helpful for evaluation and estimation of the prognosis for pNET.Grade 2 pNET: hyper and hypoenhanced and somewhat heterogeneous echotexture (arrow)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

SUN-LB89 Resolution of Hashimoto Thyroiditis: A Case of Hashimoto Thyroiditis Evolving Into Subacute Thyroiditis and Euthyroidism

Background: Subacute thyroiditis (SAT) is a transient inflammatory disorder of the thyroid gland, whereas Hashimoto thyroiditis (HT) is an autoimmune disorder. These two disease entities have quite different pathogenic mechanisms and typically do not co-occur. The objective of this report is to describe a patient with HT with eventual evolution into SAT to euthyroid. We review the diagnostic challenges of an uncommon presentation of Hashimoto thyroiditis with SAT.Clinical Case:52-year old female diagnosed with Hashimoto thyroiditis with subsequent development of hypothyroidism 10 years ago presented to our endocrinology clinic for the management of hyperthyroidism. She was diagnosed previously 10 years ago with reported elevated TSH, low FT4 and positive antibody testing assumed to include elevated anti-thyroid peroxidase. Therefore, at the time of her diagnosis she was started on levothyroxine 25 mcg daily and increased over time to 75 mcg daily. Approximately several months prior to her clinic visit with us, she began having a sore throat with subsequent development of voice hoarseness and tachycardia associated with palpitations lasting persistently for 1 month. She endorsed symptoms 2 months prior with having pain in her lower anterior neck described as non-radiating, intermittent and sharp associated with voice hoarseness, palpitations, racing heart and jitteriness that was exacerbated while palpating area. Her symptoms have since improved to having mild voice hoarseness. Her past medical history aside from hypothyroidism is Celiac disease and migraines. Her medications included Erenumab 70 mg once monthly and sumatriptan 100 mg as needed. During her evaluation, her blood pressure was 120/75, heart rate 72 bmp, temperature 36.0 C. Her physical exam was remarkable for mild tenderness of the anterior inferior midline neck without obvious masses or lesions. Ultrasound of her neck revealed heterogenous echotexture of the entire thyroid gland is noted with diffuse increased vascularity. The right thyroid lobe measured 4.2 x 1.0 x 1.5 cm and left thyroid lobe measures 4.0 x 1.0 x 1.3 cm without focal lesion is noted within either lobe. The soft tissues of the neck are unremarkable. There are no abnormal masses or fluid collections. Visualized lymph nodes are unremarkable in size and did not demonstrate increased vascularity. These findings were consistent with thyroiditis. Laboratory values obtained during her initial symptoms revealed slight hyperthyroidism with a TSH 0.05 mU/L (normal range, 0.8 to 1.7 mU/L) and FT4 2.0 ng/dL (normal range, 0.45 - 4.50 ng/dL), therefore her treatment with levothyroxine was discontinued. She was not started on any additional treatment as her symptoms were self-resolving. Repeat laboratory values in 4 weeks showed completely normal thyroid laboratory value with TSH 4.36 mU/L (normal range, 0.8 to 1.7 mU/L) and FT4 1.1 ng/dL (normal range, 0.45 - 4.50 ng/dL).Conclusion: HT is thought to be autoimmune in origin with lymphocytic infiltration and fibrosis. Early in the disease course, hyperthyroidism may result from destruction of the thyroid gland cells. HT is known to be a life-long disorder with essentially a non-functional thyroid. It is well established that SAT may evolve to HT and that HT may transform in Grave’s disease. Additionally, painful HT mimicking SAT has also been reported. There have been few reported cases of HT progressing into hyperthyroidism secondary to SAT and further resolution to euthyroid function.

SUN-500 Viral-Induced Autoimmune Hyperthyroidism in an Adult Patient Without Established Thyroid Disease

Introduction: Subacute thyroiditis is a self-limited inflammation of the thyroid associated with recent upper respiratory tract viral infection. Graves’ disease has also been associated with viral illness. Clinical Case:A 55-year-old female presented to the emergency department complaining of sore throat, cough, and shortness of breath. She also had fatigue, dyspnea on exertion, palpitations, and a family member who recently had bronchitis. She denied chest pain, weight changes, temperature intolerance, constipation, or diarrhea. She had never had similar symptoms before.On initial evaluation, the patient was febrile at 101.2 °F, tachycardic at 156 beats per minute (bpm), and tachypneic at 33 breaths per minute. She was thin and her thyroid gland was tender upon palpation. She had eyelid lag, her skin was warm, and she was diaphoretic. Chest x-ray showed increased interstitial lung markings bilaterally. CBC showed anemia with hemoglobin of 9.7 g/dL (n<12 g/dL). Lactic acid was elevated to 2.00 mmol/L (n<1.9 mmol/L). D-dimer was 3020 ng/mL (n<230 ng/mL) and BNP was 961 pg/mL (n<100 pg/mL). An electrocardiogram showed sinus tachycardia at 140 bpm. Blood, sputum, and urine cultures were drawn, as were studies for viral respiratory pathogens. CT angiography of the chest and bilateral lower extremity venous ultrasound were ordered to rule out thromboembolism.A point-of-care echocardiogram showed reduced ejection fraction of 20%. Thyroid function tests revealed TSH < 0.03 mIU/mL (range 0.5-5.0 mIU/L), free T4 of 4.5 ng/dL (n<2.15 ng/dL), and T3 251 ng/dL (n<200 ng/dL). Patient was started on an esmolol drip for heart rate control. CT angiogram of the chest was negative for thromboembolism but revealed a bilaterally enlarged thyroid gland with multiple small nodules. RNA for Respiratory Syncytial Virus (RSV) type A was detected by PCR. A thyroid ultrasound was done and revealed heterogenous echotexture with increased blast flow.Thyroid antibody studies revealed thyrotropin receptor antibody of 26.5 IU/L (n<1.75 IU/L), thyroid-stimulating immunoglobulin 19.40 IU/L (n<0.55 IU/L), thyroglobulin antibody 235.6 IU/mL (n<0.9 IU/mL), and thyroid peroxidase antibody 11 IU/mL (range 0-34 IU/mL). Patient was started on methimazole 30 mg daily. A formal echocardiogram showed preserved ejection fraction of 50-55%. She was transitioned to oral propranolol. Patient’s shortness of breath and cough resolved, and she was discharged on methimazole 10 mg daily. Conclusion:This case emphasizes the importance of measuring thyrotropin receptor antibodies in confirming Graves’ disease in a patient presenting with upper respiratory viral illness and supports the idea of viral-induced autoimmune thyroid disease.

Acute Kidney Injury With Massively Enlarged Noncystic Kidneys

Acute Kidney Injury With Massively Enlarged Noncystic Kidneys

Cervical lymphadenopathy in children: a diagnostic tree analysis model based on ultrasonographic and clinical findings.

To establish a diagnostic tree analysis (DTA) model based on ultrasonography (US) findings and clinical characteristics for differential diagnosis of common causes of cervical lymphadenopathy in children. A total of 242 patients (131 boys, 111 girls; mean age, 11.2 ± 0.3years; range, 1month-18years) with pathologically confirmed Kikuchi disease (n= 127), reactive hyperplasia (n= 64), lymphoma (n= 24), or suppurative lymphadenitis (n= 27) who underwent neck US were included. US images were retrospectively reviewed to assess lymph node (LN) characteristics, and clinical information was collected from patient records. DTA models were created using a classification and regression tree algorithm on the basis of US imaging and clinical findings. The patients were randomly divided into training (70%, 170/242) and validation (30%, 72/242) datasets to assess the diagnostic performance of the DTA models. In the DTA model based on all predictors, perinodal fat hyperechogenicity, LN echogenicity, and short diameter of the largest LN were significant predictors for differential diagnosis of cervical lymphadenopathy (overall accuracy, 85.3% and 83.3% in the training and validation datasets). In the model based on categorical parameters alone, perinodal fat hyperechogenicity, LN echogenicity, and loss of fatty hilum were significant predictors (overall accuracy, 84.7% and 86.1% in the training and validation datasets). Perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum were significant US findings in the DTA for differential diagnosis of cervical lymphadenopathy in children. • Diagnostic tree analysis model based on ultrasonography and clinical findings would be helpful in differential diagnosis of pediatric cervical lymphadenopathy. • Significant predictors were perinodal fat hyperechogenicity, heterogeneous echotexture, short diameter of the largest LN, and loss of fatty hilum.

Role of transrectal ultrasound and prostate-specific antigen density in assessment of clinically suspicious prostate cancer

Background: Prostate cancer (CaP) is a major health concern with rising incidence especially in Black African populations. Digital rectal examination (DRE), transrectal ultrasound scan (TRUS) of the prostate, and prostate-specific antigen density (PSAD) values are useful adjuncts in early diagnosis of CaP. Objective: This study was aimed at evaluating the role of TRUS and PSAD and their correlation with histopathologic findings in patients with DRE features suspicious of CaP. Patients and Methods: This research was a descriptive cross-sectional study of 100 male patients with suspected CaP based on DRE and elevated prostate-specific antigen (PSA) values recruited from the urology clinic and wards of the hospital during 2018–2019. All patients had clinical evaluation, biodata documentation, and grayscale TRUS while PSA values were determined using immunoassay method. PSAD was calculated by dividing the PSA value by the TRUS prostate volume. P ≤ 0.05 at 95% confidence interval was considered significant. Results: The mean age of patients was 66.70 ± 9.60 years with age range of 44–90 years. TRUS features of heterogeneous echotexture (n = 37; 37%), regular outline (n = 73; 73%), and intact capsule (n = 77; 77%) showed the highest frequencies. TRUS alone (P = 0.189, 0.214 and 0.265 for echopattern, outline, and capsular integrity, respectively) was not statistically significant in differentiating between benignity and malignancy. Total mean PSAD was 0.63 ± 0.32 ng/ml/cm3 while the highest mean PSAD was observed in patients with irregular glandular outline (0.74 ± 0.17 ng/ml/cm3) and in those with solitary hypoechoic nodules (0.73 ± 0.61 ng/ml/cm3). There was statistically significant correlation between PSAD values and outcome of prostate biopsy (P = 0.031). Conclusion: PSAD showed a positive correlation with outcome of prostate biopsy as well as greater predictability of CaP than TRUS which was not statistically significant in differentiating between benignity and malignancy.

Ultrasound Features of Uterine Sarcomas.

Uterine sarcomas include leiomyosarcoma, smooth muscle tumor of uncertain malignant potential, endometrial stromal sarcoma, undifferentiated sarcoma, carcinosarcoma, adenosarcoma, and rhabdomyosarcoma. Leiomyosarcomas are the most common uterine sarcomas and list some potential others. Uterine sarcomas have a wide histopathological spectrum that may display various imaging features, making the preoperative diagnosis challenging. The purpose of this review was to discuss the clinical features of uterine sarcomas, as well as their imaging appearances and characteristics. From this, practitioners can ensure that suspicious sonographic findings of uterine sarcomas, including a large-size, heterogeneous echotexture, central cystic change or necrosis, and hypervascularity, are recognized to facilitate further evaluation. Familiarity with the clinical presentations and imaging features of uterine sarcomas can lead to a more accurate diagnosis and appropriate management.

Role of ultrasound in the differentiation of parathyroid carcinoma and benign parathyroid lesions

To identify the differences between ultrasound (US) features of parathyroid carcinoma (PC) and benign parathyroid (BP) lesions in patients with primary hyperparathyroidism (PHPT). Twenty-one patients with PC and 64 consecutive patients with BP, whose diagnoses were confirmed at surgery, were enrolled from January 2013 to December 2018. The US features, demographic, clinical, and biochemical characteristics of the two groups were compared retrospectively. There are no significant differences between the patients with PC and BP regarding mean age or mean ionized calcium levels but differences were seen in sex distribution and mean parathyroid hormone (PTH) levels. On US imaging, PC significantly exhibited higher incidences of larger size and higher depth/width (D/W) ratio, heterogeneous echotexture, irregular shape, non-circumscribed margin, intra-nodular calcifications, indistinct border, cystic change, and the presence of suspicious lymph nodes compared to BP lesions. Preoperative ultrasonography is helpful to differentiate PC and BP. Patients with PC are differentiated from BP by their sex distribution, mean PTH levels, and major US characteristics: larger size, higher D/W ratio, heterogeneous echotexture, irregular shape, non-circumscribed margin, indistinct border, intra-nodular calcifications, cystic change, and the presence of suspicious lymph nodes.

Ultrasound malignancy risk stratification of thyroid nodules based on the degree of hypoechogenicity and echotexture.

The ultrasound (US) lexicon of nodule echogenicity and echotexture is one of the major differences among various risk stratification systems of thyroid nodules. This study aimed to stratify the US malignancy risk of thyroid nodules based on their degree of hypoechogenicity and echotexture. This retrospective study included a total of 2255 consecutive thyroid nodules (≥ 1 cm) with final diagnoses (malignancy rate, 13%) from 2011 to 2016. Thyroid nodules were stratified according to the US degree of hypoechogenicity (mild, moderate, or marked hypoechogenicity) and echotexture (homogeneous vs. heterogeneous). The calculated malignancy risk was compared between each category. There was no significant difference of malignancy risk between the homogeneous markedly hypoechoic and moderately hypoechoic nodules (p ≥ .18). However, the malignancy risks of markedly and moderately hypoechoic nodules were significantly higher than those of mildly hypoechoic nodules (p < .001). Heterogeneous predominantly hypoechoic thyroid nodules showed a significantly higher malignancy risk than predominantly iso- or hyperechoic thyroid nodules (p < .001). There were no significant differences of malignancy risk between heterogeneous predominantly hypoechoic and homogeneous hypoechoic nodules according to the degree of hypoechogenicity (p ≥ .12) and between heterogeneous predominantly iso- or hyperechoic nodules and homogeneous iso- or hyperechoic thyroid nodules (p = .36). The malignancy risk of nodule hypoechogenicity is stratified as mild vs. moderate to marked hypoechogenicity, and the malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity of the nodules. • Thyroid nodule echogenicity is categorized as marked, moderate, or mild hypoechogenicity and iso- or hyperechogenicity with the reference standard of adjacent thyroid tissue and anterior neck muscles. • The malignancy risk of thyroid nodule echogenicity is stratified as iso- or hyperechoic vs. mild vs. moderate or marked hypoechogenicity. • The malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity.

Case 2: Chronic Testicular Torsion in a Healthy Neonate

A male newborn, weighing 3,180 g, is born via spontaneous vaginal delivery at 38 3/7 weeks’ gestation to a 26-year-old, gravida 4, para 3 woman. The pregnancy is uncomplicated and the family history negative. At birth, the right scrotum is swollen and the left testis is not palpable. Scrotal ultrasonography shows a right hydrocele with mild swelling and reduced perfusion of the right testicle (Fig 1A and 1B). The left testicle appears to be in the left inguinal canal with blood flow present (Fig 2A and 2B). He is discharged on day 2 with outpatient follow-up scheduled with urology in 1 week. Figure 1. Sagittal views of the right testicle demonstrate course, heterogeneous echotexture and a moderate-sized hydrocele and no focal mass. Figure 2. These transverse and sagittal images of the left testicle demonstrate coarse hetrogeneous echotexture with a trace hydrocele and no focal mass. The family does not follow up, and the infant presents at 4 weeks of age with bilateral testicular swelling. On examination, the left testis is not palpable and there is diffuse scrotal swelling with no surrounding erythema. Cremasteric reflex is present on the right, but absent on the left. No chordee is noted and transillumination of scrotal skin is …

3013 Fish Mouth Ampulla: Classic Main Duct Intraductal Papillary Mucinous Neoplasm

INTRODUCTION: Intraductal Papillary Mucinous Neoplasms (IPMNs) were first identified in 1982 and there have been increasing rates of diagnosis of IPMNs in recent years with the improvement of imaging modalities. Due to the indolent course of IPMNs, many patients may initially remain asymptomatic for many years. IPMNs should be acted on quickly after diagnosis as they can progress to malignancy. We present a case of a patient who presented with symptoms similar to pancreatitis but was found to have a main duct IPMN with the classic fish mouth appearance of the ampulla. CASE DESCRIPTION/METHODS: A 62-year-old male presented to an outside hospital with epigastric abdominal pain and nausea. RUQ Ultrasound revealed normal liver and gallbladder with heterogenous echotexture within an enlarged pancreas. Abdominal CT Scan revealed a low density heterogenous, contrast enhancing, possibly multicystic lesion at the uncinate process and near the pancreatic head measuring 3.6 × 3.6 cm with dilation of the pancreatic duct. MRCP revealed a dilated pancreatic duct at 6 mm and a cystic appearing pancreatic mass involving uncinate process and portion of the right pancreatic head concerning for intraductal papillary mucinous neoplasm. He was transferred to our facility for formal Gastroenterology evaluation. EGD was performed and revealed a markedly dilated ampulla with mucinous discharge, with classic “fish mouth” appearance. The pancreatic duct was diffusely dilated from the tail to ampulla, up to 17 mm in the head/neck. A cystic lesion measuring 41 × 35 mm adjacent to the main pancreatic duct extending to the uncinate was noted. FNA was performed and pathology confirmed the diagnosis of main duct IPMN. He successfully underwent a Whipple procedure. DISCUSSION: This case illustrates the importance of recognizing a classic endoscopic feature of main duct IPMN: the fish mouth ampulla of Vater. There are three types of IPMNs: main duct, side branch and mixed. MD-IPMNs have the most malignant potential of the three and should be acted on promptly with surgical referral for resection. Approximately 65% of MD-IPMNs are malignant, compared to 20% for side branch IPMNs. Due to the indolent course of IPMNs, many patients will remain asymptomatic for many years. Eventually, patients will present with symptoms similar to pancreatitis. Despite the lack of clear consensus for management of pancreatic cystic lesions between multiple guidelines, all agree that MD-IPMNs should be surgically resected due to the high malignant potential.

Bedside ultrasound for diagnosis of appendicitis in preterm infants

Objective To investigate the sonographic features of appendicitis in preterm infants. Methods A total of 28 cases of premature infants with acute appendicitis diagnosed by bedside abdominal ultrasound in the First Hospital of Jilin University from November 2012 to January 2019 were recruited. Basic clinical information, abdominal ultrasound images, surgical results, management and outcomes were collected and analyzed. Descriptive statistical methods were used for data analysis. Results Among the 28 cases, 21 (75.0%) were males and seven (25.0%) were females. All of them were diagnosed as having acute appendicitis with perforation according to the bedside ultrasound. Five (17.8%) presented direct signs of appendicitis, i.e. partial structure of the appendix and perforation site. The other 23 (82.2%) showed indirect signs, including heterogeneous echotexture or hypoechoic patterns between the liver and right kidney in six cases, heterogeneously hypoechoic areas between the bowels in the right lower abdomen in seven cases, and dissociative effusion between the bowels in the right lower abdomen with poor sound transmission and disorder of surrounding intestinal structure in ten cases. Twenty-one out of the 28 cases (75.0%) exhibited bowel wall thickening at right lower abdomen, absence of intestinal peristalsis and effusion echoes between the intestines with poor sound transmission. Emergent surgeries were performed and diagnoses of appendicitis with perforation were confirmed. All the 21 cases were discharged after full recovery. Seven cases (25.0%) showed confined cystic images and received conservative treatment. One of them developed adhesive intestinal obstruction during follow-ups and underwent surgical treatment, during which local formations of wrapping after appendiceal perforation and obstruction due to surrounding intestinal adhesion were observed. The other six cases recovered after conservative management with gradually reduced peritoneal effusion, normal omental echo patterns and improved inflammatory indicators and abdominal symptoms, and no ileus occurred during follow-ups after discharge. Conclusions Symptoms of appendicitis in preterm infants are non-specific, and perforation is more likely to be seen. Bedside ultrasonography mainly shows indirect signs of appendicitis, and direct signs in some infants. Bedside ultrasound can be an essential tool for the diagnosis of these conditions with high accuracy. Key words: Appendicitis; Point-of-care testing; Ultrasonography; Infant, premature

SUN-609 Diagnosis of Diffuse Sclerosing Variant of Papillary Thyroid Cancer Confounded by Concurrent Postpartum Thyroiditis

Background: Diffuse sclerosing variant (DSV) is a rare and aggressive subtype of papillary thyroid carcinoma (PTC) that affects younger patients and has the sonographic features of a diffusely enlarged thyroid gland with heterogeneous echotexture and scattered microcalcifications, with or without an identifiable nodule, increased vascularity or regional lymphadenopathy (1). Clinical Case: A post-partum 25-year-old female with history of IV drug use was evaluated for thyromegaly and thyrotoxicosis. She was initially found to have generalized thyroid enlargement on exam six weeks after delivery. At that time she was asymptomatic. Thyroid function tests revealed TSH <0.01 uIU/mL (ref 0.47 - 4.68), free T4 3.47 ng/dL (ref 0.78 - 2.19), and free T3 10.2 pg/mL (ref 2.3 - 4.2). TPO antibodies were negative. Six weeks later, she developed anterior neck pain. Exam revealed a persistently enlarged thyroid gland now with tenderness to palpation. Repeat TSH was <0.01 uIU/mL. Neck ultrasound showed an enlarged thyroid gland with diffusely abnormal echotexture with suggestion of extensive microcalcifications. Color Doppler revealed diffuse hyperemia. No discrete nodule was identified. Five enlarged adjacent anterior cervical lymph nodes were identified that contained nodular foci similar to the appearance of the thyroid gland, including microcalcifications. The interpreting radiologist considered the imaging features to be compatible with DSVPTC, and recommended surgical consultation. Endocrinology was asked to evaluate via electronic consultation. Given her hyperthyroidism, anterior neck tenderness, and time course following delivery, her presentation was attributed to post-partum painful thyroiditis with reactive lymph nodes. Infectious thyroiditis was also considered. FNA was not immediately recommended due to lack of a discrete nodule on ultrasound, concern that inflammatory changes associated with active thyroiditis could lead to inaccurate biopsy results, and the fact that thyroid cancer does not typically arise from hyperfunctioning tissue. However after reiteration of concern for PTC by the radiologist, she was referred for FNA. FNA of the right thyroid lobe and one enlarged right level 3 lymph node were positive for PTC. She subsequently underwent total thyroidectomy with bilateral central neck dissection which revealed multifocal, bilateral diffuse DSVPTC without dominant nodule, with lymphatic invasion and focal angioinvasion. 37/94 lymph nodes were involved, with extranodal extension seen. Treatment with RAI is planned. Clinical Lesson(s): DSVPTC has characteristic sonographic features and may not present with a nodule; presence of these features should prompt further investigation even in the setting of an atypical clinical presentation.

Surveillance for Hepatocellular Carcinoma: Current Best Practice and Future Direction.

Hepatocellular cancer (HCC) is the fourth leading cause of cancer-related deaths worldwide and the fastest growing cause of cancer deaths in the United States. The overall prognosis of HCC remains dismal, except for the subset of patients who are diagnosed at early stage and receive potentially curative therapies, such as surgical resection and liver transplantation. Given this, expert society guidelines recommend HCC surveillance every 6 months in at-risk individuals. Despite these recommendations, the effectiveness of HCC surveillance remains a subject of debate. We discuss current best practices for HCC surveillance and the evidence that support these recommendations. We also describe several initiatives that are underway to improve HCC surveillance and outline areas that may serve as high-yield targets for future research. Overall, we believe these efforts will help the field move toward precision surveillance, where surveillance tests and intervals are tailored to individual HCC risk. Doing so can maximize surveillance benefits, minimize surveillance harms, and optimize overall value for all patients.

Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system

Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitiveand often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates. The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis. A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value(NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture). A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptomonset to ED presentation for patients with possible TT was 4h. After triage, a median of 79.8min was required for ED physician assessment and an additional 48min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration. Almost 4h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128min; Fig.1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS. Patient flow delays to surgical intervention for patients with TT representa preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.

Thyroid abscess: a rare condition in immunocompetent patient

&lt;p class="abstract"&gt;Thyroid abscess is rare due to certain anatomical and physiological characteristics of the thyroid gland. Thyroid abscess can occur due to spread of flora in the upper respiratory tract to perithyroid space and thyroid gland through fistula. We are reporting case of thyroid abscess where the infecting pathogen was &lt;em&gt;E. coli&lt;/em&gt;. USG and guided FNAC are simple and first line investigations. However there can be abscess formation following FNAC in immune compromised patients. A 50 years old man presented to us with complaints of fever and swelling over the left anterior aspect of neck of 10 days duration. It was associated with pain during swallowing. Ultrasound is investigation of choice as it does not have ionizing radiation, gives a good exposure of thyroid gland, show heterogeneous echo texture and superimposition of abscess is present. It can also show vascularity and internal haemorrhage. Patient was a case of undetected and uncontrolled diabetes mellitus which might have predisposed him to suppurative thyroiditis. Timely detection and surgical debridement of necrosed tissue and specific antibiotic treatment with management of diabetes helped him recover from this life threatening condition.&lt;/p&gt;